POLICY DOCUMENT WOMEN

Transcription

1 The Republic of Turkey PRIME MINISTRY GENERAL DIRECTORATE ON THE STATUS OF WOMEN POLICY DOCUMENT WOMEN and HEALTH 2008, ANKARA

2 This policy document analyses the situation in Turkey of women compared to men in the area of health. It has been prepared by KSGM together with six other policy documents. The policy documents cover the areas of education, economy, poverty, power and decision making, health, media and environment. These seven policy documents have been used as input for the National Action Plan Gender Equality All seven policy documents include the following paragraphs: an introduction in which the significance of the role of women in the area is stated; an overview of the past and present legal framework with regard to gender equality in the relevant area; an extensive analysis of the current situation of women compared to men based on relevant national and local statistics; a listing of the obstacles in this area for reaching gender equality; an overview of relevant government policies; and a listing of objectives and strategies for action to be implemented between 2008 and The content of the policy documents is the result of an exchange with relevant stakeholders. First a mapping exercise was performed between March and June 2007 with the aim of identifying relevant stakeholders, their roles and responsibilities and assessing the issues that needed to be addressed in the National Action Plan Gender Equality Following this activity, the draft policy documents were prepared for each area and discussed in working group meetings with relevant stakeholders. In the first meeting held in October 2007 participants had the opportunity to state their views on a draft text that presented a general summary of the current status of women in the area, the legal framework, existing government policies, and other activities carried out to improve the status of women. In a second meeting in February 2008 the same groups discussed a first draft of the objectives and strategies to be implemented. The comments of the participants have been taken into account when finalising the documents. The indicators and statistics presented in the policy documents will be used as benchmarks for monitoring the progress in gender equality. The relevant statistics will be updated every two years and will be published on the website of KSGM: ISBN September, Ankara Graphic designer: Erdener Esen - Press: Fersa Ofset -

3 TABLE OF CONTENTS 1. INTRODUCTION LEGAL FRAMEWORK CURRENT SITUATION PREVIOUS AND CURRENT POLICIES, PROGRAMMES AND PROJECTS REFERENCES LIST OF TABLES LIST OF FIGURES... 30

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5 EU Twinning Project: Promoting Gender Equality Component 4 POLICY DOCUMENT WOMEN AND HEALTH 1. INTRODUCTION Ensuring that women benefit from health services fully, equally and at the highest quality possible is a prerequisite for the achievement of full women s human rights. Being healthy is a state of complete physical, mental and social well-being and not merely the absence of a disease or infirmity. Women s health covers emotional, social and physical well-being and it is determined by social, political and economic dimensions as well as by physical ones. 1 Once women s health rights are considered within the context of human rights, it has been recognised that women s human rights include access to information on health, good nutrition and the utilization of health services. From the perspective of human rights, situations in which women are in a disadvantaged position are seen as the violation of these rights. The most extreme case of this is the maternal mortality. 2 Women s health is affected by various factors such as psychosocial factors caused by the family and the society, women s individual health condition, reproductive behaviour and the quality of the health services. When women s health is concerned, the first things that come to mind are reproductive health and family planning. However, women have other health problems besides the ones related to reproduction. Therefore, women s health should not be considered only within the context of reproductive health and family planning. Gender issues in relation to women and health can be categorised into two. The first category is related to health problems of women and morbidity risks and the second category is related to women s access to health services and to women s actual use of existing services. 1 UN Department of Public Information, Platform for Action and the Beijing Declaration, New York, 1996, paragraph AKIN, Prof. Dr. Ayşe, ESİN, Çiğdem ve CELİK, Kezban, Kadının Sağlık Hakkı ve Dünya Sağlık Örgütü nün Avrupa da Kadın Sağlığının İyileştirilmesine Yönelik Stratejik Eylem Planı, 2004, p. 2. 5

6 The health problems of women and morbidity risks are at the forefront of the issues to be tackled in the field of women and health. Women s life expectancy is higher compared to men s, however, in almost all societies, women suffer from diseases and stress more often than men. 3 The longer life span of women is one of the reasons for the higher morbidity rate among women. 4 When the reproduction-related disease burden of women and men is concerned, it is seen that women experience reproductive health problems more than men and their sensitivity increases especially during the reproductive age (ages of 15-49). 5 Furthermore, menopause related diseases occur. Employment under unhealthy working conditions and being subjected to violence, both more experienced by women, cause certain health problems, as does an unhealthy lifestyle. Another significant factor to be mentioned in the field of women and health is the social structure itself. The traditional life style and gender inequalities, still prevailing as one goes from urban to rural areas and from west to east, continue to be barriers to women s access to health services although they dissolve progressively. Gender roles deriving from the perceptions of the society are different for women and men and they bring more disadvantages to women. This poses one of the obstacles to women s access to health services. On the other hand, problems stemming from the health system are the result of situations such as shortcomings experienced in the provision of services and lack of the gender equality perspective on the side of health care personnel. This policy document is prepared to tackle important gender issues in the field of women and health. In the following parts, first the legal framework and the current situation are described, followed by a summary of previous and current policies, programmes and projects. Then based on the general picture the document reveals, policy recommendations, objectives and strategies are formulated. 2. LEGAL FRAMEWORK Constitution According to the Constitution of the Republic of Turkey the state shall ensure that everyone leads their lives in physical and mental health. The state shall regulate the central planning and functioning of the health services to secure cooperation by increasing productivity in terms of human and material resources. 6 The state fulfils this responsibility in accordance with the Law on the Socialization of Health Services, the Basic Law on Health Care Services, the Family Practitioners Law, the Social Security Law, and relevant legislation and provisions of international conventions to which Turkey is a party. Obligations Arising from International Conventions The United Nations Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), to which Turkey became a party by ratifying it in 1985, also regulates access to Health Services. Articles incorporated in the CEDAW concerning health are: 3 T.C. Sağlık Bakanlığı Anne Çocuk Sağlığı ve Aile Planlaması Genel Müdürlüğü, 2006, Cinsel Sağlık ve Üreme Sağlığı, Üreme Sağlığına Giriş, Ankara, 2006, p Idem, p Idem. 6 Türkiye Cumhuriyeti Anayasası, 1982, Madde 56. 6

7 States Parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on the basis of equality between men and women, access to health care services, including those related to family planning. Notwithstanding the provisions of paragraph I of this article, States Parties shall ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation. States Parties shall ensure to women the right to have access to adequate health care facilities, including information, counselling and services in family planning. State Parties shall grant women equal rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights. The CEDAW is a legally binding convention and the fulfilment of commitments that Turkey has undertaken are reported through Country Reports, which are submitted to the Committee every four years. The CEDAW Committee gives recommendations based on the situation in Turkey. Law on the Socialisation of Health Care Services (No. 224) The Law on the Socialisation of Health Care Services was passed in It was emphasised that within the framework of this law, relevant services would be provided to everyone equally and by giving priority to protective health care services through the approach of Basic Health Services with the aim of ensuring the utilization of health care services in line with social justice. Hence, the principle that health is a human right was accepted. According to the law health care services are defined as the elimination of various factors that are harmful to the health of human beings, the protection of the society from the influence of these factors, treatment of the patients, and medical interventions made for the rehabilitation of those whose physical and mental skills and faculties have weakened. There is not any discrimination between women and men in the provision of these services. With the law health care services are provided by giving attention and priority to significant health issues and to groups with specific needs in terms of health (like mother and children) via primary health care institutions that are established in the immediate vicinity. Through primary health care institutions, spread all over the country with over ten thousand dispensaries, over six thousand health centres and over two hundred Mother and Child Health and Family Planning Centres, comprehensive primary health care services are provided to the population of all ages and both sexes. Women are not in a decision-making position in relation to benefiting from health care services especially in rural areas and slums since their social status is low, their economic independence is inadequate, and they need help and/ or permission of their husbands or a member of the family to go to health institutions. In order to overcome this home visits are stipulated in the law especially in delivery (obstetric) and child health related services. 7

8 Basic Law on Health Care Services The Basic Law on Health Care Services was adopted in 1987 in order to regulate the basic principles with regard to health care services. Priority will be given to the protective health care services and education of citizens and followup on the protection from diseases, healthy environment, nutrition, mother and child health and family planning, and similar other issues will be carried out in cooperation with public institution-like professional organisations, private organisations and voluntary organisations under the responsibility of all public institutions. Law on the Pilot Implementation of Family Practitioners The aim of the Law on the Pilot Implementation of Family Practitioners, entered into force in 2004, is to regulate the basics of the provision of family practitioners services with the aim of improving primary health care services, concentrating on protective health services in line with the needs of individuals, keeping records of personal health, and ensuring access to these services in pilot areas to be determined by the Ministry of Health. Population Planning Law The first law on Population Planning was enacted in This law allowed the import of modern contraceptive methods, extended services in state health institutions free of charge and supported population planning education for couples. 7 In 1983 a more liberal and comprehensive Population Planning Law was passed. The new law legalises abortions (up to the tenth week of pregnancy) and voluntary surgical contraception on women and men (tubal ligation on women and vasectomy on men). 8 This law also permits the trained auxiliary health personnel to insert intra-uterine devices and certified practitioners to terminate pregnancy. Law on the Coverage of the Treatment Expenses of Citizens Lacking Means to Pay by the State through Green Card Application Through the Green Card application within the framework of this law, put into force in 1992, it is ensured that health care services are utilised by the citizens who are outside the health system as they are not under the coverage of any social security organisation, and who are also deprived of the means to pay. Citizens encountering such a situation apply to the Governorships in city centres and to Local Governorships in districts. The health expenditures of the persons found eligible for benefiting from the Green Card service are covered by the State. 3. CURRENT SITUATION Under current circumstances, women s chances of protecting and sustaining their own health are not complete and equal yet, and activities to be carried out should aim to facilitate the exercise of full control of women over all aspects of their own health. Positive developments in the field of health in Turkey in recent years can be seen as a reflection of this understanding, however, some of the problems still prevail. On the other hand, progressively more positive tables are revealed in Turkey in relation to basic health indicators. 7 TEZCAN, Sabahat, Giriş, Türkiye Nüfus ve Sağlık Araştırması 2003, Hacettepe Üniversitesi Nüfus Etütleri Enstitüsü, Ekim, 2004, Ankara, Türkiye, p Idem. 8

9 Demographic Structure and Life Expectancy at Birth The population of Turkey, showing a steady growth between , is 67,803,927 according to the latest Population Census conducted in Men and women constitute 34,346,735 and 33,457,192 of the total population respectively. According to the Address Based Population Registration System data as of 31 December 2007 the population of Turkey is 70,586,256 out of which 35,376,533 are men and 35,209,723 are women. Despite the higher life expectancy at birth for women, the data show a slightly higher male population. It is possible to interpret this situation as a high number of non-registered girls. It is obvious that this will cause various losses of rights and insufficient use of the services provided for children who are not registered as required. According to the Address Based Population Registration System data in 2007 the median age of Turkey is 28,3; for women the median age is 28.8 and for men it is Figure 1 Life Expectancy at Birth in Turkey ( ) Women Men Source: TÜİK Population and Development Indicators. In the National Action Plan prepared by Turkey in 1996 the life expectancy at birth was 70.5 for women and 65.9 for men. According to 2007 TÜİK data the life expectancy at birth was 74.2 for women and 69.3 for men. 9 Although the rise in the life expectancy at birth can be partially explained by the improvement of economic conditions, the improvement of health care services definitely has a share in the realisation of such a rise. The higher life expectancy at birth for women brings a disadvantage to women with regard to the occurrence of diseases specific to the advanced age. As a consequence of the recent high fertility rate, Turkey s population is quite young. According to 2000 data, 29 per cent of the population is 15 and below; the percentage of 65 and above is 7 per cent. When this situation is evaluated in terms of the health of women, it is concluded that the health problems of girl children and women in the fertility period should be the priority areas. 9 Türkiye İstatistik Kurumu, Nüfus ve Kalkınma Göstergeleri, Nüfus ve Demografi, Doğuşta Beklenen Yaşam Süresi Grafiği, 2007, 9

10 Furthermore, the rise of life expectancy and consequently the increase in the number of advanced aged women will require attaching more importance to the problems arising from menopause and aging as regards women s health. Turkey Demographic and Health Surveys (TNSA) have been carried out every 5 years since 1963 on a sample representing the country. The latest of these surveys was held in In the surveys data is obtained on the services extended to women during pregnancy, delivery and postnatal period, family planning services, and the situation concerning infant and child health services. In that way deficiencies and the progress made can be seen. The data below are presented basically on the basis of the TNSA data and sometimes on the basis of the findings of other surveys. Age at First Marriage Figure 2 Age at First Marriage Overall in Turkey and by Level of Education (2003) Turkey No Education High School and above Source: TNSA 2003 According to 2003 TNSA data, the median age at first marriage is 20 for women in the age group The median age at first marriage varies by the place of settlement, region and the level of education. However, overall, a steady increase is observed throughout the country in the age at first marriage. The increase in the median age at first marriage will be one of the factors affecting the decrease of the fertility rate. The most important factor increasing the median age at first marriage is the educational level of women. As the educational level of women increases, the median age at first marriage increases too. While the age at first marriage among women without education at the age group of was 18, the age at first marriage increases up to 24.8 among women with high school education and above. 10

11 Total Fertility Rate Figure 3 Total Fertility Rate in Turkey by Years ( ) total fertility rate years Source: TNSA 2003 With the improvement in the family planning services, a significant decrease has been observed concerning the total fertility rate, in other words the number of children a woman would have at the end of her fertility period. The total fertility rate was 4.33 in 1978, 2.65 in 1993 and 2.23 in The decline in the total fertility rate will bring an improvement in the health indicators of women in the coming years. When considered within the context of longterm health policies, it is possible to say that in the long-term a part of the services dedicated to mother and childcare could be transferred to other health problems of women. Table 1 Total Fertility Rate by Rural-Urban Areas, Regions and Level of Education in Turkey (2003) Region West 1.88 South 2.30 Central 1.86 North 1.94 East 3.65 Education No education/not graduated of primary school 3.65 Primary education first level 2.39 Primary education second level 1.77 High education and above 1.39 Turkey 2.23 Urban 2.06 Rural 2.65 Source: TNSA

12 The fertility rate shows significant differences by level of education, place of settlement, and geographical regions. The highest number is in Eastern Anatolia with 4 children; it decreases to 2 in Northern, Central and Southern Anatolia, and to below 2 in Western Anatolia. On average women with no education have 2 children more than women with high school education or above. Another change is the continuing upward trend in the age at first motherhood. When the total fertility rate is examined by regions, it is seen that the total fertility rate of the Eastern part of Turkey is well over the average of Turkey. This situation can be explained by reasons such as the low level of education and the low age at first marriage among women living in this region, the failure to benefit from family planning services fully, the high number of deliveries due to son preference, and the high infant mortality rate in these regions. The high fertility rate is a serious problem in terms of health of women. In this region, the family planning gap should be closed and efforts should be focused on training and awareness raising activities. Family Planning The knowledge of family planning methods is of great importance in terms of both the decision on whether to use a contraceptive method or not, and the decision on which method to use. According to 2003 TNSA, almost all evermarried and married women know at least one of the family planning methods. Furthermore, almost all women are familiar with at least one of the modern methods. The average number of methods known is another indicator of to what extent women are familiar with family planning methods. According to this, the average number of methods known by women is 8.5. Intra-uterine device and pills are the two most widely known methods among women, followed by male condoms, female sterilization, and injectable contraceptives. 71 per cent of the families currently use contraceptive methods; 43 per cent use an effective modern method and 28 per cent use traditional methods. Among all methods used intra-uterine devices are the most common ones (20.2 per cent); with regard to traditional methods withdrawal is the most common one (26.4 per cent). The use of methods varies by urban and rural areas, regions, level of education and the number of live children. Especially with the increase of the educational level of women, use of effective methods increases considerably in all regions. Figure 4 Current Use of Contraceptive Methods in Turkey by Years ( ) Any method Any modern method Source: TNSA data 12

13 When the use of contraceptive methods is concerned worldwide, according to 2003 data, it is seen that the current use of contraceptives is 60 per cent. 10 Turkey is high above the world average with 71 per cent. However, while the average of modern methods use is 54 per cent in the world 11, it is 43 per cent in Turkey. Informing the society about use of modern contraceptive methods as well as attaching importance to the widely provision of these services is necessary to close the current gap. 58 per cent of the people using contraceptive methods take this service from public institutions. Among the people receiving this service from public institutions, 1/3 gets modern methods from Mother and Child Health and Family Planning Centres (AÇSAP). A second major source is pharmacies. According to 2003 TNSA data, the total need for family planning is 76 per cent and 92 per cent of this need is met. Among married women, the rate of unmet need for family planning is 6 per cent. However, when the utilization rate of traditional methods, which is 28 per cent, is added to this, it increases to 34 per cent. This points to the fact that in terms of the health of women the unmet need for family planning is quite high and it is still a matter of concern. Another issue to be mentioned here is that Turkish law allows induced abortion. However, according to current legislation, women should secure consent of their husbands to terminate a pregnancy. Figure 5 Induced abortion in Turkey (in 100 pregnancies; ) Source: TNSA data According to 2003 TNSA data, out of 100 pregnancies, 21 do not result in live births; out of these 21, 11 are induced abortions. According to 1993 TNSA data, the rate of induced abortion was 18 out of 100 pregnancies. The decrease since 1993 can be explained by the improvements made in relation to family planning services. Maternity Welfare According to the definition by the World Health Organisation maternal death is defined as the death of a woman while pregnant or within 42 days of termination of the pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. 10 Hacettepe Üniversitesi Nüfus Etütleri Enstitüsü Türkiye Nüfus ve Sağlık Araştırması 2003, Ankara, Türkiye Ekim, 2004, ismet_turgay_sunus_tnsa-2003_02.pdf, p Idem. 13

14 The Turkey National Maternal Mortality Survey, conducted in 2005, reveals that the maternal mortality rate is 28.5 in 100,000 live births. Figure 6 Maternal Mortality Rate in Turkey (in 100,000 live births, 2005) Turkey Rural Urban Source: National Maternal Mortality Survey, 2005 While the maternal mortality rate is 40.3 in 100,000 live births in rural areas, in urban areas it is 20.7 in 100,000 live births. Despite all improvements, the maternal mortality rate is still high in Turkey compared to developed countries. The relatively high rate in rural areas is caused by the fact that important conditions such as pre-natal care, delivery under healthy conditions, age of the mother at birth, birth order, and indicators concerning the status of women are less favourable in rural areas compared to urban areas. Policy formulation processes should focus on decreasing the maternal mortality rates in rural areas. Table 2 Maternal Mortality Rate by NUTS 1 Regions (2005) (Nuts 1 regions) Maternal mortality rate (in 100,000 live births) Istanbul 11 West Marmara 42.1 Aegean 31.5 East Marmara 21.7 West Anatolia 7.4 Mediterranean 25.1 Central Anatolia 11.9 West Black Sea 26.8 East Black Sea 68.3 North East Anatolia 68.3 Central East Anatolia 36.9 South East Anatolia 38.9 Source: National Maternal Mortality Study,

15 Regional distribution (NUTS 1) of the maternal mortality rates displays that the maternal mortality rate is high above the average of Turkey in East Black Sea and North East Anatolia regions and that these are the regions to be tackled first in relation to maternal mortality. According to the 2005 National Maternal Mortality Survey preventable factors that cause maternal mortality can be categorised into three: factors related to health care providers, factors related to material/equipment used in the provision of health services, and household and social factors. Table 3 Distribution of Preventable Factors Causing Maternal Mortality (2005) Total 61.2 % Household /Social Factors 36.2 % Factors related to Health Care Providers 13.7 % Factors related to Material/Equipment used in the Provision of Health Services 2.1 % Other Risk Factors 9.6 % Source: National Maternal Mortality Study, 2005 Household factors and social factors are the most frequently encountered preventable factors both in rural and urban areas. The pregnant women s or family s failure to recognise that there is a problem, not receiving pre-natal care, and late application for receiving treatment are among the social factors causing maternal mortality. Elimination of these causes, constituting the highest rate with 36.2 per cent among the reasons of maternal mortality, necessitates focusing on awareness-raising activities. Figure 7 Receipt of Pre-natal Care from Health Care Personnel ( ) Source: TNSA data According to basic findings of the Health Seeking Behaviour Study (2007), carried out with the aim of finding out health perception and behaviour in relation to utilization of pre-natal and delivery services in the selected rural and urban areas under the scope of the Turkey Reproductive Health Programme, the general tendency during pregnancy is not to apply to any health institution unless there is a serious disease. Main elements hindering pregnant women from receiving pre-natal care are: lack of social security and economic reasons, remoteness of health institutions and therefore the difficulty to reach the institutions, the obligation to get permission from the husband or mother-in- 15

16 law, insufficiency of provided pre-natal care services, negative behaviour of health care personnel, and illiteracy of women. Other striking findings of the study are as follows: women state that they are happy with home visits; they attach importance to the fact that pre-natal care services are free of charge but they do not know that pre-natal care services provided in health centres are free of charge. Figure 8 Delivery in Health Institutions ( ) Source: TNSA data An improvement is seen in pre-natal care and delivery under healthy conditions compared to 1993 TNSA data. However, it should be noticed that one pregnant woman out of five still does not receive pre-natal care and one delivery out of six takes place without the assistance of a doctor or trained health personnel. Therefore, adoption of measures that will ensure realisation of all deliveries under healthy conditions and the receipt of pre-natal care emerges as a must. Both receipt of pre-natal care and delivery under healthy conditions increases to 99 per cent among people with secondary education and above. The same results are also observed in the use of family planning services. This shows that the social status of women is at the forefront of factors affecting the health of women and mothers and education is the main factor affecting the social status of women. In the formulation of polices regarding the health of women, this aspect should be emphasised and the health sector should fulfil its advocacy duty in this respect. In the recommendations made by the CEDAW Committee as a result of the submission and defence of the 4th and 5th Combined Periodic Country Report for Turkey in 2005, attention was drawn to the high rate of child and maternal mortality. It was also stated that adequate financial resources shall be allocated to improve the situation in health of women in terms of child and maternal mortality and required efforts shall be made in order to increase the access to health care services and to medical assistance delivered by trained health personnel especially in rural areas and in particular concerning post-natal care. 16

17 Infant and Child Mortality Although a remarkable decrease is observed in the infant mortality rate (0-1 years) and the child mortality rate (0-5 years), these rates are still high. According to 1993 TNSA, while infant mortality rate was 53 per 1,000 live births, in the 2003 TNSA, it decreased to 29 per 1,000 live births. Socio-economic reasons, low age of mother at birth, high birth order of the child, short birth intervals, and low weight at birth are the major causes of infant mortality. In 1993 the child mortality rate declined from 61 to 37 per 1,000. Although improvements in infant and child health are remarkable, the fact that the decline in still births and neonatal deaths (deaths within the first 28 days after birth) is not as high as the decline of infant and child mortality is an indicator that more importance should be attached to the health of women during pregnancy and immediately after. Adequate vaccination is one of the key programmes decreasing infant and child mortality. Vaccination rates vary by regions, educational level of the mother, sex of the child, and birth order. Table 4 Early childhood mortality rates in Turkey Infant Mortality Rate (per 1,000) Child Mortality Rate (per 1,000) PLACE OF SETTLEMENT Turkey Urban Rural REGION West South Central North East Source: TNSA 2003 As can be understood from table 4 in rural areas and in Eastern and Northern regions infant and child mortality rates are relatively high compared to overall rates in Turkey. Sexually Transmitted Infections It is seen that among all sexually transmitted infections, the most widely known by women is AIDS. According to 2003 TNSA, the rate of women knowing any other sexually transmitted infections except AIDS is 31.4 per cent. The rate of women knowledgeable about AIDS is 90 per cent. However, 31 per cent of ever-married women, a considerable high rate, does not know how to be protected against AIDS. According to the official records, from 1985 when the first AIDS case was reported to 2006, the total number of AIDS cases and carriers is 2,544. It is seen 17

18 that frequency of AIDS incidences is progressively increasing over the years. The most common method of transfer is heterosexual intercourse. There is an accumulation between the ages of and more men carry AIDS as compared to women. Table 5 Number of HIV/AIDS cases in Turkey ( ) Men Women Total 1, ,544 Source: Statistics of the Ministry of Health, The main contradiction concerning this issue is that knowledge of both women and men about other more common sexually transmitted infections is lower as compared to the level of knowledge about AIDS. However, if health programmes were conducted in accordance with the realities of the society, a contrary finding would be observed. For that reason, it would be appropriate to address this issue in the programmes and projects to be implemented in the future. Girl Children According to a regulation introduced with the Civil Code, in Turkey, girls and boys cannot get married before the age of 17. Under exceptional circumstances, the judge may permit the marriage of girls or boys at the age of 16 with their parents or legal guardian s consent. According to 2006 TÜİK data 31.7 per cent of women get married under the age of 18. An indispensable consequence of early marriage is giving birth at an early age. Although the law mandates marriage through official procedures, early marriages can be seen especially in Eastern and Southeastern Anatolia. The most severe problem arises in the field of reproductive health as a consequence of forcing girls into marriage at an early age. Practices such as early marriages, a second wife, and berdel 12 are still encountered although they are forbidden by law and generally recognised as a violation of human rights. 13 Girl children subjected to such practices come face to face with physical and psychological health risks. Such practices are explicitly identified as crimes in the Penal Code and punishments are imposed for such practices. However, elimination of the problem is possible only through education and awareness raising. Figure 9 Adolescent Fertility in Turkey ( ) Source: TNSA Berdel is used for different cultural practices such as widow marriages (a man marries the wife of his deceased brother) or a marriage in order to end a dispute between two families. 13 The Beijing Declaration and Platform for Action as well as many other international documents emphasise that this kind of practices should be eliminated. 18

19 Table 6 Fertility and maternity of adolescent women (age group 15-19) in Turkey (2003) Percentages Already mother Pregnant with first child TURKEY Urban Rural EDUCATION No education/not graduate of primary school Primary education first level Primary education second level High education and above Source: TNSA 2003 TNSA 2003 data reveal that the adolescent (10-19 age) fertility rate is 7.5 per cent. According to 1993 TNSA data the adolescent fertility rate was 9.4 per cent. Thus, progress has been made in decreasing adolescent fertility. TNSA 2003 shows the relationship between the health of girl children and education; the rate of pregnancy is higher for the adolescents who are without education and who have graduated from the first stage of primary education. Surveys conducted reveal that the maternal mortality risk is higher in adolescent pregnancies. Programmes and projects being carried out to prevent health issues related to adolescent pregnancies are presented in the Previous and Current Policies, Programmes and Projects section of this document. The evaluations about health problems of girls display that due to the traditional values, nutrition and vaccination figures of girls differ on a regional basis compared to boys. The higher schooling rate among boys in the country may be an explanation for this situation. According to the Ministry of Education 2006 data, the schooling rate in primary education is per cent for girls and per cent for boys. School attendance increases the possibility of the child to benefit from nutrition and vaccination services and at the same time increases the opportunity to notice the problems that children may encounter. In this context, the amendment made on the National Education Basic Act in 1997 in order to increase the duration of compulsory primary education to 8 years is an important improvement in terms of preventing early marriage of girls, pushing the age at first pregnancy to higher ages and ensuring access of girl children to health services through school. The Situation of Disabled Women Factors that affect the health of disabled women are listed as physical restrictions that obstruct the participation of the disabled in social life in general, insufficiency of education and psychological elements. Problems in the accessibility of institutions providing health care services, non-provision of all services needed in the institutions which are accessible, insufficient functionality of home care services are the reasons for the inadequate use of health care services by women in general. Since disabled women are more vulnerable, their morbidity risk may increase. 19

20 As disabled women can not benefit from educational opportunities adequately, they can not become fully aware of their own health situation. Ensuring that disabled women get training on health issues and making them healthconscious should be a priority in health policies. It is known that women with disabilities have more stress and psychological health problems than physical health problems. When the approach of health care personnel who approach health problems of disabled women without knowledge and in and inappropriate manner, is added to the existing problems of disabled women, miscommunication arises between the health care personnel and disabled women. This can pose on obstacle to the utilization of health services by disabled women. Current Situation Concerning the Pilot Implementation of Family Practitioners Practice of Family Practitioners started on 15 September 2005 in Düzce in accordance with relevant provisions. It is implemented in 20 provinces, 238 public health centres and 3,708 Family Practitioners Units and servesa population of 12 million people as of February million people with 10,375 family practitioners in 59 provinces will be reached by the end of PREVIOUS AND CURRENT POLICIES, PROGRAMMES AND PROJECTS Mother and child health and family planning services have been among the priorities of government policies. Various programmes have been implemented in which provinces identified as priority provinces in development, slums in metropolitan cities, rural areas, and specific risk groups are addressed. Such programmes are still ongoing since children and women within the fertility age group have a big share in the population and the infant mortality rate, child mortality rate, and maternal mortality rate are high. There is a big need for family planning services and pre-natal and post-natal services are not at the desired level. In this document a selection will be made among programmes and projects and the ones most relevant for the subject and covering the widest application area will be presented. Cairo Conference Turkey has ratified the recommendations of the International Conference on Population and Development held in Cairo in 1994, without any reservations. After this date it made its traditional mother and child health approach more comprehensive. Turkey started to develop programmes that address women and men in a holistic manner with a life cycle approach and started to regulate types and scopes of the services according to needs. 4th World Conference on Women Turkey, participating in the 4th World Conference on Women held in Beijing in 1995, has ratified the Beijing Declaration and Platform for Action. Concerning health, which is one of the 12 critical areas of concern identified in the Beijing Platform for Action, States Parties committed themselves to: 20

21 increase women s access throughout the life cycle to an appropriate, affordable and high-quality health care, information and related services; strengthen preventive programmes that promote women s health; improve reproductive health; increase resources and research on women s health. Development Plans The national 5-year development plans, covering all fields where the state is active, provide for various regulations in the field of health. Within the implementation period of the Eight Development Plan ( ) progress was made in relation to indicators such as health care personnel, infant mortality rate, and immunization. However, indicators have not reached the desired level yet and there are differences in the delivery of health care services on a regional basis and between rural and urban areas. Within the execution period of the Eigth Development Plan a pilot on family practitioners was implemented. The total health expenditures has increased from 6.6 per cent of the total Gross Domestic Product (GDP) in 2000 to 7.6 per cent of the GDP in While the rate of population under the social security in terms of health care services was 80.9 per cent in 2000, it increased to 91 per cent in The numbers of inpatient beds and physicians which are important indicators of the access to health services and their share in the population are expected to improve during the Ninth Development Plan period ( ). It is stated in this plan that in order to improve access to health services: the infrastructure and health care personnel needs will be met and their distribution around the country will be balanced; the general health insurance system will be implemented to facilitate access to health services; the quality of health services, particularly in primary level health services, will be enhanced; the family medicine service model will be spread to all provinces by the end of 2008; priority will be given to mother and child care and preventive health care services; barriers to access to health care services of particularly the handicapped, the elderly, women, children and migrants, and groups subjected to poverty and social exclusion will be dismantled. 15 Gender Equality National Action Plan (1996) In this Action Plan, which was developed by Turkey in 1996 in accordance with the Action Plan (Beijing) of the 4th World Conference on Women, health was addressed as one of the main critical areas of concern, and targets and actions to be taken were set out following the completion of analysis concerning problems encountered by women in the field of health. In this Action Plan objectives of increasing women s access to high quality health services, 14 Uzun Vadeli Strateji ve 8 inci Beş Yıllık Kalkınma Planı , 15 Idem. 21

22 developing preventive programmes to improve the health of women, launching gender sensitive initiatives on sexual health, spreading researches about health of women, increasing resources on women s health, and eliminating all practices that have an adverse effect on the health of women were set. 16 Implementation of the National Action Plan was not successful since responsible parties were not identified explicitly and monitoring and evaluation processes were not defined. However, it is worth mentioning because it was Turkey s first National Action Plan attempt in the field of gender equality and goals related to health were set in the Plan. National Strategic Action Plan on Sexual Health and Reproductive Health for the Health Sector The Health of Women and Family Planning- National Strategic Action Plan, prepared for the first time in 1996 in parallel with ICPD and aiming to primarily address the status of women and reproductive health, was implemented until 2000 in line with the objectives set. The Plan was updated in 2005 as the National Strategic Action Plan on Sexual Health and Reproductive Health for the Health Sector in accordance with the developments and needs arising. The Plan identifies targets, priorities and things to be done in Turkey in the period In this strategic plan priorities are defined as reducing maternal mortality, preventing unwanted pregnancies, improving the health of the youth, preventing sexually transmitted infections, and decreasing inequalities between regions in the field of health. One of the major targets is to reduce the overall maternal mortality rate by 50 per cent by the year 2015 as compared to Within this framework, targets for each geographical region and settlement unit will be determined separately. And secondly, differences between regions and settlement units will be decreased by 50 per cent by the year To attain these targets the number of women receiving pre-natal care and deliver under healthy conditions will be increased. Also prenatal mortality rate, neonatal mortality rate, maternal mortality rate and the rate of those giving birth before the age of 20 will be decreased. The targets determined for the prevention of unwanted pregnancies, another priority area, are to cover family planning need in all Turkey and geographical units and settling units for 100 per cent by 2013 and to decrease the differences between regions and settling units by 50 per cent by The third critical area was identified as preventing and decreasing the frequency of sexually transmitted diseases and HIV/AIDS cases. The targets identified to attain this objective are to decrease sexually transmitted diseases throughout Turkey and in the geographical regions and to minimise regional disparities. The fourth critical area is to increase sexual health and reproductive health levels of the youth. It is aimed to reduce adolescent pregnancies, to increase youth friendly sexual health and reproductive health services in all Turkey and geographic units and to reduce the disparities between regions and settlement units in relation to the provision of these services. 16 KSSGM, 1996 Ulusal Eylem Planı, Ankara, Ağustos 1998, p

23 Reproductive Health Programme of Turkey The key objective of the Reproductive Health Programme of Turkey, implemented between in accordance with agreements between the government and the European Commission, is to give direct support to the activities of the Ministry of Health by increasing use, accessibility and the quality of services in the field of reproductive health. The Programme also aims at supporting non-governmental organisations through grants that will enable NGOs to carry out various activities with the overall aim of increasing the demand for services. The overall target of the Programme is to improve the reproductive health situation of the population, especially that of women and youth. The specific targets are to increase the use of sexual health and reproductive health services and to improve the policy in relation to these subjects. By the end of the Programme it is expected to reach the following results: Scope and coverage of reproductive health service provision will be increased; Access to services will be increased; Quality of sexual health and reproductive health services will be increased; Awareness of the youth in relation to sexual health and reproductive health needs and respond to that kind of needs will be increased; Members of parliament, policy makers and decision makers have more knowledge about rights and preferences concerning sexual health and reproductive health and have better understanding of these rights and preferences; Disparities between rural and urban areas and between East and West will be reduced. The first component of the Reproductive Health Programme of Turkey supports the Ministry of Health for improving the quality of service and for strengthening the institutional capacity. The second component is to cooperate with NGOs with the aim of increasing the demand for sexual health and reproductive health services and to strengthen NGOs. Through training programmes carried out under the first component of the Programme in total 75 Reproductive Health Training Centres (12 of which are regional) were established. In addition to the 18 Youth Counselling and Health Service Centres established by the Ministry of Health previously, 20 more Youth Counselling and Health Service Centres started to work. Also training material was developed and pre-graduation and in-services trainings were provided. In addition, activities of supporting service delivery units and actions on sexually transmitted diseases were carried out and the need for information was met. In total 55 million financial support was provided for the Reproductive Health Programme of Turkey; 20 million of the total amount was used for 88 projects run by NGOs. 23

24 National Action Plan for Combating Domestic Violence Against Women The National Action Plan for Combating Domestic Violence Against Women sets three implementation periods: short-term, medium-term and long-term. The objective of the Plan is to implement the measures required for the elimination of all forms of domestic violence against women. 17 The National Action Plan for Combating Domestic Violence Against Women, prepared in 2007 with the contributions and cooperation of all relevant parties, was put into implementation with the approval of State Minister in charge of Women and Family. One of the six targets of the National Action Plan is to ensure organisation and provision of curative and rehabilitation services towards women victimized by domestic violence, and perpetrators. 18 In the Plan domestic violence against women is described as a public health problem that affects both women as the victims of violence and the perpetrators. Domestic violence against women requires comprehensive curative and rehabilitative health services. Activities to be undertaken to solve this problem and the responsible parties are determined. Crisis Intervention Centres Various measures are taken to prevent attempts to commit suicide which stem from psychological disorders and which are also observed among women. Under the scope of studies launched by the Ministry of Health in ,056 health staff members have been trained in Education Boards formed in provinces. Another pillar of prevention initiatives is completing the physical infrastructure of pilot hospitals in 32 provinces under the scope of the Psychosocial Support to Suicide Attempts in Emergency Units and Crisis Prevention Programme. Within the same scope Psycho-social Support and Crisis Intervention Units, established within emergency units of hospitals, started their operations in February 2006 as a result of the training of 9,463 health staff members. As of July 2008 Psycho-social Support and Crisis Intervention Units provide services in 49 provinces and in 97 hospitals. Training on the Role of Health Care Personnel in Combating Domestic Violence Against Women and Procedures to be Applied The protocol Training on the Role of Health Care Personnel in Combating Domestic Violence Against Women and Procedures to be Applied was signed by the State Minister in charge of Women and Family Affairs and the Ministry of Health on 3 January This protocol has been prepared through cooperation of the Prime Ministry General Directorate on the Status of Women and the Ministry of Health General Directorate of Basic Health Services with the aim of determining health service procedures provided to victims of violence and women under risk and organising training programmes. Through trainings primarily 500 trainers will be trained and then reach 75,000 health personnel working in the field will be reached. Turkish Armed Forces Reproductive Health Programme The Turkish Armed Forces Reproductive Health Programme was launched in 2002 with the cooperation between the Ministry of Health, the Turkish Armed Forces Health Command and the United Nations Fund for Population 17 KSGM, National Action Plan for Combating Domestic Violence Against Women , p Idem, p